iv drip Intravenous drip by liaoqinmei

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									                                                                                                                                                                      Duration of                                                                                                           CCU/PACU
                                                 Normal units in                                                                                                      effect when             MRMC Recommended                                                                              /ER/
                                                 which drip is     MRMC standard              Primary short-term                Half-                                 infusion is             Nursing Monitoring                                                                            Cardiac cath Cardiac/surgical Medical                                  Cardiac
Drug                 Use                         ordered           concentration              side effects                      life     Onset         Peak           stopped                 Parameters         usual dose                                      maximum dose               lab          stepdown         telemetry                                telemetry                Notes
Amiodarone           Treatment/prophylaxis of mg/min               1.8 mg/ml provided as      hypotension (Usually within 1st   15-100   Prompt,      Days            Days                    Continous EKG monitoring .          load:150 mg over 10 min doses > 2100 mg/day          May initiate and         May initiate and maintain Maintain fixed     May initiate and               *run through filter set
(Cordarone)          VT/VF, supraventricular                       450 mg/250 ml dextrose     few hours, rate related),         days     usually                                              BP monitoring: q 15 min x4, then    (max rate of 30 mg/min)    associated with increased maintain                 up to 1 mg/min            infusion up to   1 maintain up to                 *in glass bottle for infusion
                     arrythmia,cardiac arrest                      or 900 mg/500 ml           arrythmia ,ARDS                            within hr                                            q 30 min x2,then q 1hr x2, then q   maintenance: 1 mg/min x 6 hypotension                                                                   mg/min in stable   1 mg/min                       greater than 2 hr
                                                                   dextrose glass bottle                                                                                                      4hr                                 hr then 0.5 mg/min. Rate                                                                                patient                                           * conc greater than 2 mg/ml
                                                                                                                                                                                                                                  may be adjusted, but >                                                                                                                                    must be run through central
                                                                                                                                                                                                                                  2100 mg/day associated                                                                                                                                    line
                                                                                                                                                                                                                                  with increased hypotension                                                                                                                                *monitor QT interval and report
                                                                                                                                                                                                                                                                                                                                                                                            prolongation to physician


Fenoldopam           Short term control (up to   mcg/kg/min        10 mg/250 ml which is 40 cardiac arrhythmia,                 5 min    5-15 min     15-20           15 min-4 hr             Continous EKG monitoring.        0.1 to 1.7 mcg/kg/min.    1.7 mcg/kg/min                     May initiate,        no                         no                     no                       *Monitor serum potassium at
(Corlopam)           48 hr) of severe                              mcg/ml                   hypotension,hypokalemia                                   min,another                             BP monitoring: q 15 min x4, then doses < 0.1 mcg/kg/min                                       maintain and titrate                                                                            least q 6 hr initially.
                     hypertension                                                                                                                     text lists 30                           q 30 min x2,then q 1hr           usually have modest                                                                                                                                          *Maximum recommended
                                                                                                                                                      min-2 hr)                                                                effects, usual                                                                                                                                               infusion is 48 hour
                                                                                                                                                                                                                               recommended starting
                                                                                                                                                                                                                               dose is 0.1 mcg/kg/min
                                                                                                                                                                                                                               and adjust by 0.05
                                                                                                                                                                                                                               mcg/kg/min- 0.1
                                                                                                                                                                                                                               mcg/kg/min q 15 min (less
                                                                                                                                                                                                                               frequently as bp goal
                                                                                                                                                                                                                               approached)

Diltiazem (Cardizem) temporary control of rapid mg/hr              1 mg/ml                    arrhythmia, hypotension, CHF      3.4 hr   1-3 min if   2-7 minutes     0.5-10 hr after drip    Continous EKG monitoring.           bolus: initial: 0.25 mg/kg     15 mg/hr. Some          May initiate,          May initiate, maintain       may initiate and      May initiate,            *Maximum recommended
                     ventricular rate in atrial                                                                                          started with after bolus     turned off              BP monitoring: q 15 min x4, then    over 2 min. max bolus:         physicians use up to 20 maintain, titrate      fixed infusion rate, titrate maintain fixed        maintain fixed           duration is 24 hr. Check with
                     fibrillation or flutter,                                                                                            bolus.                                               q 30 min x2,then q 1hr x2, then q   0.35 mg/kg over 2 min.         mg/hr                   (20 mg/hr              up to 15 mg/hr               infusion rate up to   infusion rate, titrate   MD about switching to oral
                     conversion of PSVT to                                                                                                                                                    4hr                                 maintenance: 5-15 mg/hr                                maximum)                                            15 mg/hr              up to       15 mg/hr     formulation after 24 hr-first
                     NSR                                                                                                                                                                                                                                                                                                                                                                    dose of oral medication usually
                                                                                                                                                                                                                                                                                                                                                                                            given before stopping infusion
                                                                                                                                                                                                                                                                                                                                                                                            *multiple incompatibilities
                                                                                                                                                                                                                                                                                                                                                                                            including heparin and
                                                                                                                                                                                                                                                                                                                                                                                            furosemide
                                                                                                                                                                                                                                                                                                                                                                                            *prepared as 1:1 drip by adding
                                                                                                                                                                                                                                                                                                                                                                                            125 mg of diltiazem (which is
                                                                                                                                                                                                                                                                                                                                                                                            contained in 25 ml of solutioin)
                                                                                                                                                                                                                                                                                                                                                                                            to 100 ml of diluent for a total
                                                                                                                                                                                                                                                                                                                                                                                            volume of 125 ml and a final
                                                                                                                                                                                                                                                                                                                                                                                            concentration of 1 mg/ml




DoPAmine             hypotension,CHF             mcg/kg/min        800 mg/250 ml which is     arrhythmia,                       2 min    5 min                        very short after drip   Continuous EKG monitoring, .        2-20 mcg/kg/min. up to 50      20 mcg/kg/min unless       May initiate,       May initiate, maintain      no                     May initiate,            *Extravasation requires
                                                                   3200 mcg/ml                hypertension,vasoconstriction,                                          turned off              BP monitoring: q 15 min x 4, then   mcg/kg/min has been            specifically instructed by maintain, titrate   fixed infusion rate up to                          maintain flat infusion   treatment. If available,
                                                                                              necrosis with extravasation                                                                     q 30 min x2, then q 1h x2, then q   used, but is not               physician to go higher.                        10 mcg/kg/min,titrate up                           rate up to 5             phentolamine is the preferred
                                                                                                                                                                                              4hr.                   Urine        recommended                    Doses up to and beyond                         to 10 mcg/kg/min                                   mcg/kg/min               agent. If unavailable,
                                                                                                                                                                                              output. Daily weight         For                                   50 mcg/kg/min have                                                                                                         nitroglycerin is used (see note
                                                                                                                                                                                              all doses > 10 mcg/kg/min: q 2 hr                                  been used                                                                                                                  at end of table)
                                                                                                                                                                                              peripheral pulse and extremity                                                                                                                                                                *note: look alike/sound alike
                                                                                                                                                                                              checks.                                                                                                                                                                                       drug with doBUTamine. Check
                                                                                                                                                                                                                                                                                                                                                                                            order and IV bag carefully.



DoBUTamine           short term inotropic        mcg/kg/min        500 mg/250 ml which is     arrhythmia, hypertension,         2 min    2 min        10 min          very short after drip   Continuous EKG monitoring, .        2-20 mcg/kg/min. up to 40 20 mcg/kg/min unless       May initiate,            May initiate, maintain      May initiate,          May initiate,            *note: look alike/sound alike
(Dobutrex)           support                                       2000 mcg/ml                hypotension, increased HR                                               turned off              BP monitoring: q 15 min x 4, then mcg/kg/min has been         specifically instructed by maintain, titrate        fixed infusion rate up to   maintain fixed         maintain fixed           drug with DoPAmine. Check
                                                                                                                                                                                              q 30 min x2, then q 1 hr x2, then q used, but increases       physician to go higher.                             10 mcg/kg/min,titrate up    infusion rate up to    infusion rate up to      order and IV bag carefully.
                                                                                                                                                                                              4hr. Urine output. Daily weight. potential for toxicity                                                           to 10 mcg/kg/min            10 mcg/kg/min          10 mcg/kg/min


Eptifibitide (Integrilin) acute coronary syndrome mcg/kg/min       75 mg/100 ml premixed       bleeding-usually from invaded    2.5 hr   bolus         1 hr           2-4 hr                  FOR ALL PATIENTS: check              180 mcg/kg bolus x1 over      2 mcg/kg/min for patients May initiate,        May initiate,maintain       No                     May initiate and         Monitor for bleeding or signs
**Note: not a             and PCI                                  bottle which is 0.75 mg/ml site or GI or GU sites                     followed by                                          creatinine clearance and verify      1 min (for acute coronary     (with maximum dose of maintain                                                                    maintain in precath      and symptoms of bleeding.
vasoactive drip, but                                               Note: Eptifibitide is also                                            infusion                                             dose. (NOTE: CREATININE              syndrome) or x2 (for PCI      20 ml/hr of the 0.75                                                                              patients or patients     Report any bleeding or
frequently used in                                                 available in a 20 mg/10 ml                                            produces                                             CLEARANCE CALCULATOR                 with boluses 10 min           mg/ml infusion) with                                                                              not going to cath lab    changes in vital signs or status
cardiac areas                                                      vial that is to be used for                                           immediate                                            AVAILABLE ON BON SECOURS apart;each bolus over 1                   creatinine clearance                                                                                                       suggestive of bleeding to
                                                                   the bolus only                                                        inhibition,                                          INTRANET. CONTRAINDICATED min), then 2 mcg/kg/min                  greater than or equal to                                                                                                   physician immediately.
                                                                                                                                         steady state                                         IN DIALYSIS PATIENTS).Monitor (for creatinine clearance            50 ml/min.                                                                                                                 NOTE: two sizes of bottles
                                                                                                                                         reached in 4-                                        patients for signs/symptoms of       greater than or equal to 50   1 mcg/kg/min for patients                                                                                                  stocked. 2 mg/ml 10 ml vial is
                                                                                                                                         6 hr                                                 bleeding.                            ml/min) or 1 mcg/kg/min       (with maximum dose of                                                                                                      for bolus. 0.75 mg/ml 100 ml
                                                                                                                                                                                              FOR PRECATH PATIENTS AND (for creatinine clearance                 10 ml/hr of the 0.75                                                                                                       vial is for infusion
                                                                                                                                                                                              PATIENTS NOT GOING TO                less than 50 ml/min)          mg/ml infusion) with
                                                                                                                                                                                              CATH LAB: continuous EKG                                           creatinine clearance
                                                                                                                                                                                              monitoring, vital signs and check                                  less than 50 ml/min.
                                                                                                                                                                                              of invaded sites and neurochecks
                                                                                                                                                                                              q 1 hr x 4,then q 2hr x2, then q 4
                                                                                                                                                                                              hr; heme test all stools;gastroccult
                                                                                                                                                                                              all emesis. POSTCATH
                                                                                                                                                                                              PATIENTS: per cath lab protocol




Epinephrine          vasopressor                 mcg/min           2 mg/250 ml which is 8     anxiety, pallor, palpitations,    short    rapid                        short                   continuous EKG monitoring          1-10 mcg/min                    10 mcg/min                 may initiate,       no                          no                     no                       *multiple drug interactions and
(Adrenalin)                                                        mcg/ml                     profound vasoconstriction and                                                                   BP monitoring: q 5 min until                                                                  maintain, titrate                                                                               contraindicated drug
                                                                                              compromise of renal and gut                                                                     stable, then q 15 min x 4, then q                                                                                                                                                             combinations.
                                                                                              blood flow, hypertension                                                                        30 min x2, then q 1 hr. Peripheral
                                                                                                                                                                                              pulse and extremity checks q 2 hr.
                                                                                                                                                                                              urine output.
                                                                                                                                                                                     Duration of                                                                                                       CCU/PACU
                                                  Normal units in                                                                                                                    effect when               MRMC Recommended                                                                        /ER/
                                                  which drip is              MRMC standard              Primary short-term                Half-                                      infusion is               Nursing Monitoring                                                                      Cardiac cath Cardiac/surgical Medical                           Cardiac
Drug                   Use                        ordered                    concentration              side effects                      life       Onset          Peak             stopped                   Parameters         usual dose                                         maximum dose      lab          stepdown         telemetry                         telemetry            Notes
Esmolol     (Brevibloc) SVT, intraoperative and   mcg/kg/min                 2.5 grams/250 ml which is hypotension, bradycardia,          1-2 min    1-2 min                         within 30 min             continuous EKG monitoring.        FOR SVT: load: 500         300 mcg/kg/min for         May initiate,         no                   no                   no                   *for short term use only*
                        postoperative                                        10 mcg/ml                 inflammation of infusion site.                                                                          BP monitoring: q 15 min x4, then mcg/kg over 1 min,          hypertension. 200          maintain, titrate
                        hypertension and/or                                                            Beta-blockers, such as esmolol,                                                                         q 30 min x2, then q 1 hr         continuous infusion at 50- mcg/k/gmin for SVT
                        tachycardia                                                                    may cause arrhythmia, angina,                                                                                                            200 mcg/kg/min (start at
                                                                                                       MI,death if stopped abruptly.                                                                                                            50 mcg/kg/min. after 4
                                                                                                                                                                                                                                                minutes, may give
                                                                                                                                                                                                                                                additional bolus and
                                                                                                                                                                                                                                                increase rate by 50
                                                                                                                                                                                                                                                mcg/kg/min. As desired
                                                                                                                                                                                                                                                effect is approached,
                                                                                                                                                                                                                                                eliminate bolus and titrate
                                                                                                                                                                                                                                                in increments of 25-50
                                                                                                                                                                                                                                                mcg/kg/min. May increase
                                                                                                                                                                                                                                                titration time from 5 to 10
                                                                                                                                                                                                                                                min. FOR
                                                                                                                                                                                                                                                HYPERTENSION: as for
                                                                                                                                                                                                                                                SVT, but may require
                                                                                                                                                                                                                                                doses up to 300
                                                                                                                                                                                                                                                mcg/kg/min. May also give
                                                                                                                                                                                                                                                80 mg IV over 1 minute
                                                                                                                                                                                                                                                followed by 150
                                                                                                                                                                                                                                                mcg/kg/min infusion if
                                                                                                                                                                                                                                                needed. titrate as needed.



Ibutilide              rapid conversion of afib or ordered as 1 mg or less   may be given undiluted or ventricular arrhythmias, including 6 hr       conversion                                                continuous EKG monitoring while      >60 kg: 1 mg over 10                               initiate              initiate             no                   initiate             *While administering, staff
(Corvert)              aflutter of short duration to                         diluted in 50 ml of NS or torsades de pointes. (risk                    usually                                                   administering and for 4 hr after     minutes. May repeat x1 10                                                                                                               ratio must be 1:1. Patient must
                       sinus rhythm                                          D5W and given as an         increases with QTc interval > 440           occurs                                                    finishing, or longer if arrythmia    min after end of first                                                                                                                  be placed on lifepack with
                                                                             infusion. MRMC              msec, K less than 4, pts on other           within 30                                                 occurs or patient has liver          infusion if arrhythmia is not                                                                                                           multifunction pads attached
                                                                             recommends an infusion, Class Ia or III antiarrythmics-in               min, but                                                  dysfunction.                         terminated. If < 60 kg,                                                                                                                 while receiving and for at least
                                                                             but in either case the dose clinical studies held for 5 t1/2            may occur                                                 BP monitoring: q 15 min x 4, then    0.01 mg/kg over 10 min,                                                                                                                 4 hr afterward (longer if
                                                                             should be given over 10 prior to giving ibutilide and for 4             up to 90 min                                              q 30 min x 2, then q 1 hr x2, then   may repeat x1 10 minutes                                                                                                                arrhythmia occurs or liver
                                                                             minutes                     hr after)                                                                                             q 4 hr                               after end of first infusion if                                                                                                          dysfunction )
                                                                                                                                                                                                                                                    arrhythmia is not                                                                                                                       *watch QT interval for
                                                                                                                                                                                                                                                    terminated                                                                                                                              prolongation
                                                                                                                                                                                                                                                                                                                                                                                            *risk of torsades de pointes
                                                                                                                                                                                                                                                                                                                                                                                            *hypokalemia, hypomagnesia
                                                                                                                                                                                                                                                                                                                                                                                            should be corrected prior to
                                                                                                                                                                                                                                                                                                                                                                                            administration (electrolyte
                                                                                                                                                                                                                                                                                                                                                                                            abnormalities increase risk of
                                                                                                                                                                                                                                                                                                                                                                                            arrhythmia)
                                                                                                                                                                                                                                                                                                                                                                                            *patients should not receive
                                                                                                                                                                                                                                                                                                                                                                                            other Class Ia or Class III
                                                                                                                                                                                                                                                                                                                                                                                            antiarrhythmics (quinidine,
                                                                                                                                                                                                                                                                                                                                                                                            procainamide, disopyramide,
                                                                                                                                                                                                                                                                                                                                                                                            bretylium, amiodarone, sotalol)
                                                                                                                                                                                                                                                                                                                                                                                            concominantly with ibutilide or
                                                                                                                                                                                                                                                                                                                                                                                            for 4 hours afterward, and
                                                                                                                                                                                                                                                                                                                                                                                            these agents should preferably
                                                                                                                                                                                                                                                                                                                                                                                            be held for five half-lives prior
                                                                                                                                                                                                                                                                                                                                                                                            to administering ibutilide.
                                                                                                                                                                                                                                                                                                                                                                                            These agents increase risk of
                                                                                                                                                                                                                                                                                                                                                                                            arrhythmia.




Isoproterenol          atropine-resistant          mcg/min                                             tachycardia, hypotension, cardiac 3-7 hr      immediate                       1-2 hr                    continous EKG monitoring.        atropine resistant       30 mcg/min in advanced initiate,maintain,           no                   no                   no
(Isuprel)              hemodynamically                                                                 ischemia, cardiac arrythmias                                                                            BP monitoring: q 15 min x4, then bradycardia: 2-20        shock. Administer for 1 titrate
                       significant bradycardia,                                                                                                                                                                q 30 min x2, then q 1hr          mcg/min, shock:0.5-5     hr or less in septic shock
                       shock, diagnosis of mitral                                                                                                                                                                                               mcg/min up to 30 mcg/min
                       regurgitation, diagnosis of
                       CAD, refractory torsade
                       de pointes, beta-
                       adrenergic blocker
                       poisoning


Labetalol (Trandate, hypertension,decrease bp mg/min                         500 mg/250 ml which is 2 hypotension (especially postural    5 hrs,     5-20 min                        with bolus                continous EKG monitoring.           0.5-2 mg/min.             see previous column       initiate, maintain,   no                   no                   no
Normodyne)           and symptoms in patients                                mg/ml                    orthostatic hypotension), less      some                                       administration: 3-6 hr,   BP monitoring: q 15 min x4, then recommended to stop                                    titrate
                     with pheochromocytomia                                                           likely to cause bradycardia than    effects                                    with BP returning to      q 30 min x2, then q 1 hr x2, then q infusion when max of 300
                                                                                                      other beta-blockers,ventricular     may last                                   baseline in 16-18 hr      4 hr. Maintain patient in supine    mg is reached or
                                                                                                      arrhythmia (1%)                     up to 16                                                             position                            satisfactory response is
                                                                                                                                          hr                                                                                                       achieved (and begin oral
                                                                                                                                                                                                                                                   form), but has been used
                                                                                                                                                                                                                                                   as continuous infusion in
                                                                                                                                                                                                                                                   CCU patients at 1-180
                                                                                                                                                                                                                                                   mg/hr for up to 9 days


Lidocaine              treatment or prophylaxis of mg/min                    2 grams/250 ml D5W        anaphylaxis, cardiac arrest, qrs 1.5-2 hr     45-90 sec                       10-20 min after single continuous EKG monitoring               usually bolus followed by 4 4 mg/min               initiate, maintain    initiate, maintain   no                   initiate, maintain   Obtain serum levels with use
                       vfib/v tach, status                                   which is 8 mg/ml          widening, tremor,                             after bolus                     bolus                                                          mg/min                                                                                                                                  greater than 24 hours or
                       epilecticus (unlabeled                                                          twitching,confusion,nervousness                                                                                                                                                                                                                                                      suspected toxicity. Half-life
                       use)                                                                                                                                                                                                                                                                                                                                                                 increases over time and
                                                                                                                                                                                                                                                                                                                                                                                            infusion rate may require
                                                                                                                                                                                                                                                                                                                                                                                            decrease
Milrinone (Primacor) short term management        mcg/kg/min                 20 mg/100 ml D5W which arrhythmia, hypotension               1-3 hr                    10 min if load                             continuous EKG monitoring            load: 50 mcg/kg over             0.75 mcg/kg/min   initiate, maintain    initiate, maintain   initiate, maintain   initiate,maintain    *not shown to be safe or
                     of acute decompensated                                  is 200 mcg/ml                                                                          given                                      BP monitoring: q 15 min x 4, then    10min, then infusion at                                                                                                                 effective for more than 48 hr
                     heart failure                                                                                                                                                                             q 30 min x2, then q 1 hr x 2 and     0.375 mcg/kg/min- 0.75
                                                                                                                                                                                                               then q 4 hr.                 daily   mcg/kg/min. Decrease
                                                                                                                                                                                                               weight. Urine output                 dose with renal
                                                                                                                                                                                                                                                    dysfunctiion
                                                                                                                                                                  Duration of                                                                                                        CCU/PACU
                                                Normal units in                                                                                                   effect when               MRMC Recommended                                                                         /ER/
                                                which drip is     MRMC standard           Primary short-term                 Half-                                infusion is               Nursing Monitoring                                                                       Cardiac cath Cardiac/surgical Medical                    Cardiac
Drug                 Use                        ordered           concentration           side effects                       life        Onset          Peak      stopped                   Parameters         usual dose                                  maximum dose              lab          stepdown         telemetry                  telemetry               Notes
Nesiritide (Natrecor) treatment of acutely      mcg/kg/min        1.5 mg/250 ml which is 6 hypotension                       18 min      60 % of 3 hr             half of recovery of sbp   continuous EKG monitoring            2 mcg/kg bolus over 1 min, 0.03 mcg/kg/min          may initiate and      may initiate and maintain no       may initate and         *IV tubing should be primed
                      decompensated chf in pt                     mcg/ml                                                     (but        effect of                toward baseline after     BPmonitoring q 15 min x 4, then q    then 0.01 mcg/kg/min.                               maintain                                                 maintain                with 25 ml of infusion prior to
                      with dyspnea at rest or                                                                                pharmaco    pcwp reduct              d/c is seen with 60       30 min x2, then q 1 hr x 2 and       May increase dose as                                                                                                                 administration of bolus or
                      minimal activity                                                                                       dynamic     seen in 15               min. hypotension may      then q 4 hr. daily weight. Urine     follows: 1 mcg/kg bolus                                                                                                              infusion
                                                                                                                             half-life   min, 95%                 last several              output                               followed by increase in rate                                                                                                         *use limited to 48 hours
                                                                                                                             longer,     seen in 1                hr.following d/c pcwp                                          of 0.005 mcg/kg/min.                                                                                                                 *hypotension when it occurs
                                                                                                                             and         hour,75% of              within 10 % of                                                 Increases may be made as                                                                                                             can be prolonged.
                                                                                                                             hypotensi   3 hr sbp                 baseline within 2 hr                                           frequently as q 3 hr to max                                                                                                          *Concurrent use of other IV
                                                                                                                             on may      reduction                                                                               of 0.03 mcg/kg/min.                                                                                                                  vasodilators or oral
                                                                                                                             last        reached                                                                                                                                                                                                                      antihypertensives may be
                                                                                                                             several     within 15                                                                                                                                                                                                                    additive
                                                                                                                             hours       min                                                                                                                                                                                                                          *If hypotension occurs,
                                                                                                                                                                                                                                                                                                                                                                      nesiritide may be restarted
                                                                                                                                                                                                                                                                                                                                                                      once BP stabilized if ordered by
                                                                                                                                                                                                                                                                                                                                                                      physician-infusion rate should
                                                                                                                                                                                                                                                                                                                                                                      be reduced by 30% and no
                                                                                                                                                                                                                                                                                                                                                                      bolus should be given
                                                                                                                                                                                                                                                                                                                                                                      *must run through dedicated
                                                                                                                                                                                                                                                                                                                                                                      line


Nitroglycerin (Tridil) Unstable angina, CHF,    mcg/min           50 mg/250 ml D5W        headache, hypotension,             2-30 min    1-2 min                  5-10 min                  continuus EKG monitoring BP        initial: 5-10 mcg/min.      doses up to 1000       initiate, titrate,       initiate, maintain, titrate   no   initiate, maintain flat *contraindicated in patients
                       hypertension                                                       tachycardia                                                                                       monitoring: q 15 min x4, then q 30 adjusted upward as          mcg/min have been used maintain                 up to 50 mcg/min                   rate, titrate up to 20 using sildenafil (Viagra),
                                                                                                                                                                                            min x2, then q 1 hr x2, then q     needed (usually by units of but our maximum is 200                                                             mcg/min                 vardenafil (Levitra) or taldalafil
                                                                                                                                                                                            4hr.frequent assessment of chest 5-20 mcg/min depending mcg/min without                                                                                                   (Cialis) which are erectile
                                                                                                                                                                                            pain                               upon indication and current physician approval                                                                                         dysfunction agents
                                                                                                                                                                                                                               dose).                                                                                                                                 *safe interval between use of
                                                                                                                                                                                                                                                                                                                                                                      sildenafil or vardenafil and
                                                                                                                                                                                                                                                                                                                                                                      nitroglycerin has not been
                                                                                                                                                                                                                                                                                                                                                                      determined. levels at 24 hr
                                                                                                                                                                                                                                                                                                                                                                      after sildenafil are much lower
                                                                                                                                                                                                                                                                                                                                                                      than at peak.
                                                                                                                                                                                                                                                                                                                                                                      *for taldalafil, the interaction is
                                                                                                                                                                                                                                                                                                                                                                      present up to and including 24
                                                                                                                                                                                                                                                                                                                                                                      hr after taldalafil. At 48 hours,
                                                                                                                                                                                                                                                                                                                                                                      the interaction by most
                                                                                                                                                                                                                                                                                                                                                                      hemodynamic measures was
                                                                                                                                                                                                                                                                                                                                                                      not seen, but some taldalafil
                                                                                                                                                                                                                                                                                                                                                                      patients had a greater drop in
                                                                                                                                                                                                                                                                                                                                                                      blood pressure than placebo
                                                                                                                                                                                                                                                                                                                                                                      patients. Beyond 48 hours
                                                                                                                                                                                                                                                                                                                                                                      interaction is not detectable.




nitroprusside        hypertensive emergency, mcg/kg/min           100 mg/250 ml D5W       hypotension, sweating, EKG        3-4 min      30-60 sec      1-2 min   1-10 min                  continuous EKG monitoring            0.1-5 mcg/kg/min.           see previous column     initiate, maintain,   only post-carotid surgical no      no                      * contraindicated in patients
                     acute CHF, cardiogenic                       which is 400 mcg/ml     changes, increased ICP, muscle                                                                    ;continuous BP monitoring: BP        absolute max is 10                                  titrate               patient                                                    taking Viagra, Levitra or Cialis
                     shock                                                                twitching, restlessness, cyanide                                                                  documentation at least q 5 min til   mcg/kg/min which                                                                                                                     (see nitroglycerin note)
                                                                                          toxicity, methemoglobinemia,                                                                      stable, then q 15 min x4, then q     should never be run for                                                                                                              *symptoms of cyanide
                                                                                          thiocyanate toxicity. Cyanide                                                                     30 min x2, then q 1 hr .             more than 10 min. best to                                                                                                            toxicity are air hunger, bright
                                                                                          results from the breakdown of                                                                                                          avoid doses > 3                                                                                                                      red venous blood,
                                                                                          nitroprusside in the body. The                                                                                                         mcg/kg/min in pt with nl                                                                                                             confusion,restlessness,
                                                                                          elimination of cyanide depends                                                                                                         renal function and doses >                                                                                                           agitation convulsions,
                                                                                          upon its conversion to                                                                                                                 1 mcg/kg/min in anuric                                                                                                               cardiovascular instability
                                                                                          thiocyanate; how much cyanide                                                                                                          patients b/c thiocyanate                                                                                                             metabolic acidisos (ANION
                                                                                          may be processed depends upon                                                                                                          levels require several days                                                                                                          GAP METABOLIC ACIDOSIS
                                                                                          the amount of thiosulfate in the                                                                                                       to come back from lab.                                                                                                               IS ONE OF EARLIEST, MOST
                                                                                          body (stores may be depleted in                                                                                                        Doses greater than 2                                                                                                                 CONSISTENT FINDINGS).
                                                                                          chronically or critically ill                                                                                                          mcg/kg/min may result in                                                                                                             Treatment of cyanide toxicity is
                                                                                          patients). Thiocyanate is then                                                                                                         cyanide toxicity.                                                                                                                    d/cing infusion, oxygen and
                                                                                          eliminated by the kidney.                                                                                                                                                                                                                                                   sodium thiosulfate.
                                                                                          Whether cyanide toxicity develops                                                                                                                                                                                                                                           *symptoms of thiocyanate
                                                                                          depends upon the rate of                                                                                                                                                                                                                                                    toxicity are primarily CNS in
                                                                                          nitroprusside infusion (prolonged                                                                                                                                                                                                                                           nature including weakness,
                                                                                          infusions or rates greater than 2                                                                                                                                                                                                                                           tinnitus, agitation, tremor,
                                                                                          mcg/kg/min can result in cyanide                                                                                                                                                                                                                                            hallucinations,lethargy. may
                                                                                          toxicity) and the amount of                                                                                                                                                                                                                                                 also include abdominal pain
                                                                                          thiocyanate the patient's body                                                                                                                                                                                                                                              and vomiting. Treatment is
                                                                                          contains. Whether thiocyanate                                                                                                                                                                                                                                               hemodialysis.
                                                                                          toxicity develops depends upon                                                                                                                                                                                                                                              *Methemoglobinemia is
                                                                                          the amount of thiocyanate formed                                                                                                                                                                                                                                            characterized by cyanosis
                                                                                          (which depends on the                                                                                                                                                                                                                                                       unresponsive to oxygen,
                                                                                          nitroprusside infusion rate) and                                                                                                                                                                                                                                            despite normal arterial oxygen
                                                                                          the patient's renal function.                                                                                                                                                                                                                                               tension




Norepinephrine       hypotensive state          mcg/min           8 mg/250 ml D5W which   anxiety,arrhythmias, chest pain,   1-2 min                                                        continuous EKG monitoring,           0.5 to 30 mcg/min. (usual 40 mcg/min                initiate, maintain,   no                            no   no                      *Extravasation requires
(Levophed)                                                        is 32 mcg/ml            ischemia, necrosis with                                                                           continuous BP monitoring: BP         8-12 mcg/min initially,                             titrate                                                                          treatment. If available,
                                                                                          extravasation                                                                                     documentation at least q 5 min til   maintainance usually 2-12                                                                                                            phentolamine is the preferred
                                                                                                                                                                                            stable, then q 15 min x4, then q     mcg/min. Alternatively may                                                                                                           agent. If unavailable,
                                                                                                                                                                                            30 min x2, then q 1 hr .             start with 0.5-1 mcg/min,                                                                                                            nitroglycerin is used (see note
                                                                                                                                                                                            Peripheral pulse and extremity       and titrate as needed to 2-                                                                                                          at end of table)
                                                                                                                                                                                            checks q 2 hr. Urine output          12 mcg/min) .


Phenylephrine        hypotension                mcg/min           10 mg/250 ml D5W which bradycardia,hypertension,tremors 1-2 min        1-2 min                  15 min                    continuous EKG monitoring,           40-180 mcg/min. usually 200 mcg/min                 initiate,maintain,titr only post-carotid surgical no     no                      *Extravasation requires
(Neosynephrine)                                                   is 40 mcg/ml           , ventricular                                                                                      continuous BP monitoring:            begin at 100-180 mcg/min,                           ate                    patient                                                   treatment. If available,
                                                                                         tachycardia,ventricular                                                                            documentation of BP q 5 min til      unitl bp stabilized, then                                                                                                            phentolamine is the preferred
                                                                                         extrasystoles, extravasation                                                                       stable, then q 15 min x4, then q     decrease to 40-60                                                                                                                    agent. If unavailable,
                                                                                         causes necrosis                                                                                    30 min x2, then q 1 hr .             mcg/min                                                                                                                              nitroglycerin is used (see note
                                                                                                                                                                                            Peripheral pulse and extremity                                                                                                                                            at end of table)
                                                                                                                                                                                            checks q 2 hr.
                                                                                                                                                 Duration of                                                                                           CCU/PACU
                                          Normal units in                                                                                        effect when   MRMC Recommended                                                                        /ER/
                                          which drip is     MRMC standard             Primary short-term               Half-                     infusion is   Nursing Monitoring                                                                      Cardiac cath Cardiac/surgical Medical         Cardiac
Drug             Use                      ordered           concentration             side effects                     life       Onset   Peak   stopped       Parameters         usual dose                               maximum dose                lab          stepdown         telemetry       telemetry            Notes
Procainamide     ventricular tachycardia    mg/min          4 grams/500 ml D5W or 2 hypotension, PR interval           2.5-8 hr                                continuous EKG monitoring           may give up to 20 mg/min 6 mg/min maintenance       initiate, maintain   initiate,maintain   no   initiate, maintain
(Pronestyl)      when lidocaine                             grams/250 ml D5W which prolongation, QRS widening, QT                                              BP monitoring: q 15 min x4, then    in loading dose phase (up
                 contraindicated or has not                 is 8 mg/ml              interval prolongation, ventricular                                         q 30 min x2, then 1 hr x2, then q   to maximum of 1 gram).
                 suppressed, wide-complex                                           arrhythmias, blood dyscrasias,                                             4hr. Keep patient supine            Maintenance: 1-4 mg/min
                 tachycardias difficult to                                          lupus like syndrome
                 distinguish from VT




**treatment of extravasation for dopamine, norepinephrine, phenylephrin: RNs may initiate phentolamine (Regitine) therapy following dopamine, phenyleprine or norepinephrine infiltration in peripheral IV sites.                                  T
The IV is discontinued immediately and phentolamine therapy is initiated within one hour of infilitration (per nursing policy PF726). If phentolamine is unavailable,
nitroglycerin ointment may be used. For adults, 1 inch is applied to the afected area and may be repeated q 6-8 hr if ischemia continues or returns.

								
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